Anal fissure

This is a narrow tear in the skin of the anus, no bigger than a paper cut, yet the pain it causes is in a class of its own. People start to dread the toilet, put the visit off, the stool hardens, and the next time hurts even more. That circle can usually be broken without surgery, and the sooner it is tackled, the easier it goes.

What tears, and why it will not heal on its own

The lining of the lower anus is thin and extremely sensitive. Hard stool, or conversely repeated loose stool, tears it, almost always at the back, in the midline. From there a self-feeding circle begins: the pain triggers a cramping squeeze of the internal sphincter muscle, the tightened muscle presses on the small blood vessels, and not enough blood reaches the edges of the tear. A wound like this anywhere else on the body would close in a few days; here it stays open for weeks. That is why treatment is aimed less at the wound itself than at relaxing the muscle and softening the stool.

When the tear lasts longer than six to eight weeks it is called chronic: the edges thicken and a small skin tag appears beside it, which is often taken for a pile.

How it feels

• a sharp, cutting pain at the moment of passing stool, which many describe as passing broken glass;
• a burning afterwards that lasts from a few minutes to several hours;
• a few drops of bright red blood on the paper or on top of the stool, not mixed into it;
• itching and dampness in the area;
• a fear of the toilet and deliberate holding on — the most harmful symptom of the lot.

In small children it is all the same, only they cannot put it into words: the child cries on the potty, tenses up, holds on. The cause is nearly always constipation.

How it differs from piles

Both conditions produce bright red blood and both are common, but they feel different. Piles tend to bother people with itching, heaviness and a sense of something being there, and they sometimes bleed heavily and almost painlessly. A fissure gives a short, sharp, extremely intense pain tied precisely to the moment of opening the bowels, and bleeds only a little. The distinction matters, because ointments for piles do next to nothing for a fissure, and months of applying them are months lost.

What to do in the first few weeks

The main task is to make stool soft and regular. That alone heals most recent tears.

• More fibre: vegetables, fruit, grains, bran. If food alone is not enough, a doctor will choose a bulk-forming laxative or a gentle osmotic one.
• Enough fluid — without it, fibre only makes the stool firmer.
• Go as soon as the urge comes. Every postponed attempt dries the stool out further.
• Do not strain and do not linger. Leave the phone outside: five minutes is the limit.
• A warm sitz bath for ten to fifteen minutes after passing stool, which relaxes the cramped muscle and noticeably eases the pain.
• Wash with water rather than using rough paper, and pat dry.
• An ordinary painkiller by mouth if the pain is bad; a short course of an ointment with a local anaesthetic can also be used.
• Move about more — the bowel responds to this better than one would think.

With this sort of care a recent fissure heals in two to six weeks. It is worth keeping the stool soft for a couple of months after the pain has gone: it is precisely on the return to old habits that a fissure usually comes back.

When it is not an ordinary fissure

This is the most important part. An ordinary fissure sits in the midline, at the back or, in women who have given birth, at the front. Anything that looks different calls for investigation: several tears at once, a position to the side, undermined edges, a painless ulcer, hardening underneath it. Behind such a picture can lie Crohn's disease and other inflammatory bowel diseases, syphilis, herpes, HIV, tuberculosis and occasionally a tumour of the anus.

See a doctor without delay if any of these appear:

• fever, increasing swelling, throbbing pain, discharge of pus — that is how an abscess beside the anus shows itself, and it is drained urgently;
• heavy bleeding, dark blood or black stools;
• weight loss, night sweats, prolonged diarrhoea, blood mixed with mucus;
• pain and bleeding for the first time after the age of fifty;
• no improvement after six to eight weeks of care at home;
• a fissure that keeps coming back.

What the doctor will do

The diagnosis is usually made on simple inspection: the tear is visible when the skin is gently parted. A digital examination is normally avoided while the pain is acute, since it is unbearable and adds nothing. If there is doubt, if the pain makes examination impossible, or if another cause is suspected, an examination under anaesthetic is offered. For people over fifty, and for anyone with weight loss, anaemia or a change in bowel habit, the bowel itself is also checked so that a more serious source of bleeding is not missed.

Treatment when it does not heal by itself

The next step is ointments that relieve the spasm of the sphincter. Two classes are used: nitrates and calcium channel blockers in topical form. They are applied over six to eight weeks, and for most people that is enough. Headache is a common side effect of nitrates; with topical calcium channel blockers it happens less often.

If ointments fail, there is an injection of botulinum toxin into the muscle: it lifts the spasm for a time and gives the fissure a chance to close. Finally, for a stubborn chronic fissure a small operation is performed — dividing part of the internal sphincter muscle. It heals most reliably but carries a risk of weakened control, most often of wind, so it is discussed separately and is not offered first. For women who have given birth another route is sometimes chosen: covering the defect with a flap of skin, without cutting the muscle.

What is not worth doing: using steroid ointments for months on end, since they thin the skin and do nothing for healing.

Online consultation: how it helps

Seeing the fissure itself needs a face-to-face visit, but most of the work around it does not hinge on that. A doctor online can work out from your description whether this looks more like a fissure, like piles or like an abscess; set out a clear plan for diet, laxatives and sitz baths; explain how to apply the prescribed ointments and how long to wait for an effect; advise on a child who holds on and is frightened of the potty. Most importantly, it helps separate the situation that home care will settle from the one that cannot wait. Many people put up with this complaint for years out of sheer embarrassment, and starting the conversation from home is easier.

This material is for information only and does not replace medical advice.